Medication-Psychotherapy Combination Most Effective for Schizophrenia

Medication-Psychotherapy Combination Most Effective for Schizophrenia

"Can we talk?" asks a recovering patient who chastises psychiatry for too readily dismissing patients with her diagnosis as unable to benefit from talking therapy (A Recovering Patient, 1986). With managed care administrators quick to seize upon a lack of outcome data as a pretext for limiting treatment and a public mental health system pressed to handle caseloads as high as 200 to 300 patients per clinician, psychiatry's regrettable answer has often been: "No, we're too busy." Recent research findings, however, convincingly demonstrate that a flexible form of individual psychotherapy, when combined with appropriate neuroleptic medication, can yield improvements in social and vocational functioning unobtainable with "treatments as usual."

Gerard Hogarty, M.S.W., and colleagues at the University of Pittsburgh School of Medicine report in the November 1997 American Journal of Psychiatry the first rigorous scientific data to support the efficacy of a disorder-specific individual psychotherapy (Hogarty et al., 1997a, 1997b).

Personal Therapy (PT), a flexible form of individual psychotherapy, was evaluated among 151 recently discharged outpatients with schizophrenia or schizoaffective disorder receiving maintenance neuroleptics. Results of the randomized clinical trial indicated that the social adjustment and role performance of patients treated with supportive case management and/or family therapy plateaued after 12 months. Conversely, patients receiving PT continued to improve over the entire three-year trial with no evidence of a plateau. Furthermore, over three years, remarkably few (six in 74 or 8%) patients receiving PT were dropped from the treatment program because of noncompliance or other reasons.

Contentious History

The value of psychotherapy for schizophrenia has long been the subject of contentious debate within psychiatry. Early in the century most clinicians considered the disorder untreatable. Kraepelinian "organic" psychiatrists viewed schizophrenia as a progressive brain deterioration; Freudian psychoanalysts viewed it as a "narcissistic neurosis" where transference, and hence cure, was not possible. Despite widespread therapeutic nihilism, a few early renegades were drawn to talk and spend time with the incurable.

Based on his intuition that "like can help like" and, perhaps, his own experience with a psychotic episode, Harry Stack Sullivan ran a unit for young men with schizophrenia at the Sheppard and Enoch Pratt Hospital in Towson, Md., during the 1920s. He staffed the unit with shy, introverted male attendants and observed that providing an experience of reciprocal trust--which he felt many patients had missed during critical periods of development--could be beneficial by allowing a "validation of personal worth." Sullivan described schizophrenic psychopathology as the lasting residue of unsatisfactory interpersonal experiences, and saw a basic mistrust of others as central to the condition.

Later, under the leadership of Dexter Bullard Sr., a group of psychoanalysts and social scientists, including the German refugee Frieda Fromm-Reichmann, at Chestnut Lodge Hospital, Rockville, Md., explored the therapeutic potential of Sullivan's ideas by attempting to talk with patients.

Fromm-Reichmann summarized these efforts in her Principles of Intensive Psychotherapy (1950), the first description of what later became known as intensive psychodynamic psychotherapy. In the decades before the introduction of neuroleptic medications, heroic efforts to establish contact with acutely ill and unmedicated patients were described in the works of Searles (1965), Burnham et al. (1969), and others. The patient's expectation of harm from others, marked ambivalence in relationships, difficulty separating personal thoughts and impulses from those of others, and pervasive passivity were thought to be correctable.

The introduction of chlorpromazine (Thorazine) in 1954 dramatically transformed the treatment of schizophrenia and placed a therapeutic tool of unparalleled efficacy in the hands of biologically oriented psychiatrists. Proponents of individual psychotherapy, however, largely rejected medications as covering up the problems of schizophrenia. Professional views became polarized and debate between competing factions acrimonious.

While randomized clinical trials unambiguously showed the value of medications, trials that compared various forms of individual psychotherapy with other treatments provided no scientific evidence for the efficacy of individual psychotherapy as the sole treatment for schizophrenia. In addition, long-term follow-up studies conducted at Chestnut Lodge and elsewhere showed that most patients treated with psychotherapy alone remained seriously and chronically disabled (McGlashan, 1984, 1988). The biological paradigm gained decisive ascendancy in American psychiatry.

The Boston Psychotherapy Study was later conducted by Gunderson et al. (1984) to compare the efficacy of supportive psychotherapy (as practiced by biologically oriented psychiatrists) and psychodynamic psychotherapy against a backdrop of adequate medications for all patients (Gunderson et al., 1984; Stanton et. al., 1984). Contrary to the investigators' expectations, neither treatment emerged as clearly superior, and both were limited by very high (60% to 70%) dropout rates.

Independent of level of psychopathology, however, the investigators found that patients able to achieve a good therapeutic alliance in the first six months were more likely to remain in treatment, comply with medication and achieve better outcomes. Despite differing ideologies, supportive and psychodynamically oriented therapists tended to actually use similar techniques--for both therapies, a sound dynamic understanding of the patient's concerns was associated with better results.

Changing Paradigms

Today, debates about drugs versus psychotherapy or supportive versus psychodynamic care are no longer salient. No single approach can claim to ameliorate all symptoms and disabilities of schizophrenia (Lehman, 1995). As reflected in the American Psychiatric Association's 1997 Practice Guideline for the Treatment of Patients with Schizophrenia (APA, 1997), treatment most often requires the sophisticated integration of several pharmacologic, psychosocial and rehabilitative strategies.

When many treatment modalities are required, someone is needed to orchestrate and coordinate them. This can often be best accomplished by a psychiatrist providing continuity of care within a flexible long-term psychotherapeutic relationship. While medications improve symptoms and cognition, and rehabilitation can remediate social and vocational skills, a psychotherapeutic relationship can address the human aspects of suffering from a serious and long-term disorder.